Neuroleptic malignant syndrome following alcohol withdrawal: A case report

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening emergency precipitated by the use or withdrawal of dopamine-receptor antagonists or dopaminergic agents. It classically presents with lead-pipe rigidity, hyperthermia, autonomic dysregulation, and altered mental status. Delayed recognition still carries considerable mortality. Alcohol-withdrawal syndrome (AWS) ranges from mild tremor to delirium tremens and overlaps with NMS in fever, agitation, and autonomic instability, making early distinction difficult. We describe a middle-aged man with alcohol-use disorder who developed NMS during treatment of AWS after intramuscular haloperidol. Given significant hepatic dysfunction, dantrolene was avoided; ICU-level supportive care with continuous intravenous midazolam was provided. He improved clinically and biochemically; lorazepam was tapered off and he was discharged. Overlapping pathophysiology—particularly reduced central dopaminergic tone in withdrawal states—may lower the threshold for NMS. A high index of suspicion for NMS is warranted in patients with AWS after antipsychotics administration. In the presence of hepatic impairment, drug choice and dosing should be tailored to liver function.